Long-term outcomes of lower extremity graft preservation using antibiotic beads in patients with early deep wound infections after major arterial reconstructions

Dreaded Late Complications: Infection, Blowout, Pseudoaneurysm, Fistula

“…These include edema, subsequent superficial wound separation, underlying hematoma or seroma formation, disrupted lymphatics, and non-healing wounds that can all lead to bacterial invasion [1]. Independent predictors of SSI after vascular lower extremity reconstructions include obesity, antiplatelet medication, and previous vascular surgery, particularly for aneurysmal disease and implantation of prosthetic conduits, dialysis dependence, hypertension, intraoperative thrombosis, prolonged operative time, high peak intraoperative glucose, and surgery performed at a larger hospitals or major teaching centers [2,11].…”

“…Early infections, occurring within the first 4-6 months, are most likely due to common gram-positive skin contaminants such as S. aureus and Streptococcus [11,14,17]. However, late graft infections are caused mostly by insidious, slow growing, low virulence organisms.…”

“…Early peripheral infections tend to present with overt signs of high-grade infection such as drainage, dehiscence, or an abscess (Fig. 16.1), with or without systemic response [11], and have been associated with higher rates of bleeding from anastomotic disruption due to proteolytic characteristics of the more virulent bacteria [19]. Late, or delayed, infections typically present after the first year.…”

“…Graft preservation is most suitable for patent femoral or distal grafts with infection limited to the bed of the graft and not involving suture lines, in patients not presenting with sepsis or hemorrhage. Graft preservation should not be considered in the presence of high virulence organisms such as Pseudomonas [5,11,28]. Wound sterilization begins with thorough operative debridement and copious irrigation, with or without adjuncts such as betadine, hydrogen peroxide, or bacitracin.…”

“…The technique consists of creating antibiotic beads intraoperatively by mixing polymethyl methacrylate powder with vancomycin and either tobramycin or gentamicin, rolling the mixture into small beads, linking them on a suture while solidifying, and once the thermal reaction has cooled they are inserted into the wound which is then sutured closed. Serial washouts and antibiotic bead exchanges are continued every 3-5 days until negative cultures are obtained, requiring a range of 1-3 explorations after initial bead placement [4,11]. At the time of final closure, muscle flap coverage should be considered in the case of significant graft exposure or large soft tissue defects.…”